TABLE OF CONTENTS DEVELOPMENT JOB DESCRIPTIONS

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL TABLE OF CONTENTS SECTION I ADMINISTRATION SECTION II SERVICE PROVISION SECTION III CLIENT RECORDS SECTION IV PSYCHOSOCIAL REHABILITATION SECTION V PERSONNEL AND STAFF DEVELOPMENT JOB DESCRIPTIONS SECTION VI QUALITY ASSURANCE SECTION VII ACCESS / CRISIS INTERVENTION Last Revised: 4/17

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL TABLE OF CONTENTS SECTION I SUBJECT ADMINISTRATION PAGE(S) 1. Access to CPRC Policies and Procedures 1 2. Orientation/Continuing Education of Board 2 3. Organization 3 4. Location and Hours 4 5. Philosophy and Purpose 5-6 6. Outreach Plan for Services 7-8 7. Client Feedback and Recommendations 9 8. Program Goals 10 9. Research 11 10. Client Rights 12-13 11. Confidentiality of Records 14 12. Client Abuse and Neglect 15-23 13. Inappropriate Client Behavior 24 14. Behavior Management 25-26 15. Behavioral Crises 27 16. Medical Emergencies 28 17. Off-Site Emergencies 29 18. Emergency Response in Case of Vehicle Accident 30 19. Infection Control: AIDS 31 20. Infection Control: All Diseases 32-33 21. Death of a Client 34-36 22. Arrest or Detention of a Client 37 23. Emergency Procedures 38-40 24. Van Maintenance 41 25. Use of Tobacco 42 Last Revised: 4/17

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL TABLE OF CONTENTS SECTION I (continued) ADMINISTRATION Attachments Attachment A Incident Report Form Attachment B Internal Incident Report Form Attachment C Emergency Drill Report Form Attachment D Vehicle Inspection Report Form Attached NORTH CENTRAL MISSOURI CPRC Last Revised: 4/17

MENTAL HEALTH CENTER MANUAL TABLE OF CONTENTS SECTION II SERVICE PROVISION SUBJECT PAGE(S) 1. CPRC Services 1-2 2. Admission Criteria 3-9 3. Initial Evaluation 10-12 4. Admission Procedure 13 5. Refusal of Admission 14-15 6. Client Status 16 7. Waiting List 17 8. Treatment Planning/Goals and Objectives 18-21 9. Annual Evaluation 22 10. Community Support 23-25 11. Client Assignment 26-27 12. Critical Intervention Plan 28-29 13. Crisis Intervention and Resolution 30-33 14. Medication Services 34-35 15. Medication Administration Services 36-39 16. Abnormal Involuntary Movement Scale 40 17. Off-Site Services 41 18. Transfer and Referral 42-43 19. Coordination with Inpatient Treatment 44 20. Missed Appointments 45 21. Transportation 46 22. Discharge from CPRC 47 23. Intensive CPRC 48-51 24. Healthcare Home 52-59 25. ITCD 60-77 Last Revised: 4/17 4

Attachments Attached Attachment A AIMS Last Revised: 4/17 NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL TABLE OF CONTENTS SECTION III SUBJECT CLIENT RECORDS PAGE(S) 1. Administration and Storage 1 2. Monitoring 2 3. Standards 3 4. Intake/Initial Evaluation 4-5 5. Individual Treatment/Rehabilitation Plan 6-7 6. Quarterly Reviews 8 7. Annual Evaluation 9-10 8. Progress Notes 11-12 9. Psychosocial Rehabilitation 13 10. Crisis Intervention and Resolution 14 11. Discharge from CPRC 15 Attachments Attachment A CommCare Form Attached NORTH CENTRAL MISSOURI Last Revised: 4/17 5 CPRC Last Revised: 4/17

MENTAL HEALTH CENTER MANUAL TABLE OF CONTENTS SECTION IV SUBJECT PSYCHOSOCIAL REHABILITATION PAGE(S) 1. Philosophy and Purpose 1-2 2. Admission Criteria 3 3. Core Services 4-5 4. Costs 6 5. Intake Screening and Admission 7-8 6. Intake and Assignment Procedures 9 7. Client Rights 10-11 8. Behavior Management 12-13 9. Client Abuse and Neglect 14-19 10. Confidentiality Policy 20 11. Health and Safety Program 21-36 12. Documentation 37 13. Client Rights Team 38 14. Grievance Procedures 39-40 15. Client Layoff from PSR 41 16. Missing or Runaway Clients 42-42 17. Discharge from PSR 43-44 18. Medication 45-47 19. Client Input 48 Attachments Attachment A Field Trip Permission Form Attachment B PSR Introduction Sheet Attachment C PSR Preferences Form Attached Last Revised: 4/17 Last Revised: 4/17 6

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL TABLE OF CONTENTS SECTION V SUBJECT PERSONNEL AND STAFF DEVELOPMENT PAGE(S) 1. Table of Organization 1 2. Hiring Procedures 2 3. Personnel Policies and Procedures 3 4. Volunteers 4-5 5. Staff Supervision Practices and Ratios 6-7 6. CPRC Director Job Description 8 7. Children & Youth Services Director Job Description 9 8. CPRC Team Leader Job Description 10 9. Community Support Specialist 11 10. PSR Team Leader Job Description 12 11. PSR Worker Job Description 13 12. Transportation Coordinator Job Description 14 13. Transportation Aide Job Description 15 14. Professional Growth and Development 16-21 Attachment A Table of Organization Attachment B Background Check Form Attachment C CPRC Director Job Description Attachment D Children and Youth Services Director Job Description Attachment E CPRC Team Leader Job Description Attachment F CPRC Community Support Specialist Job Description Attachment G PSR Team Leader Job Description Attachment H PSR Worker Job Description Attachment I Transportation Coordinator Job Description Attachment J Transportation Aide Job Description Attachment K Orientation and Continuing Education Checklist Last Revised: 4/17 7

Last Revised: 4/17 8 Last Revised: 4/17

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL TABLE OF CONTENTS SECTION VI SUBJECT QUALITY ASSURANCE PAGE(S) 1. Quality Assurance Committee 1-2 2. Clinical Privileging Process 3-4 Directions for Completing Application for Clinical Privileges 5 Attachments Attachment A Clinical Privileging Process Attachment B Clinical Privileging Application Attached Last Revised: 4/17 Last Revised: 4/17 9

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL TABLE OF CONTENTS SECTION VII SUBJECT ACCESS / CRISIS INTERVENTION PAGE(S) 1. Treatment 1-14 2. Client Records 15-17 3. Personnel and Staff Development 18-20 4. Quality Assurance 21-22 Attachments Attachment A Client Alert Form Attachment B Risk Assessment Attachment C Crisis Contact Sheet Attachment D Safety Plan Attachment E Safety Protocol Check Form Attachment F ACI Quality Assurance Plan Attached Last Revised: 4/17 10 Last Revised: 4/17

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: ACCESS TO CPRC POLICIES AND PROCEDURES SECTION NO. I SUBJECT NO. 1 The CPRC Policies and Procedures Manual is the basis for orientation and continuing education of CPRC staff. Current copies of the manual will be maintained in the offices of the Executive Director, Executive Assistant, Clinical Director, CPRC Director, and Children s Services Director, as well as all of the agency s satellite offices. Last Revised: 4/17 11

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: ORIENTATION/ CONTINUING EDUCATION OF BOARD SECTION NO. I SUBJECT NO. 2 The Executive Director of North Central Missouri Mental Health Center will attend all scheduled Board of Directors meetings and report on the overall operation of the agency s programs, including the CPRC. The CPRC Director will attend periodically throughout each year to orient the board and report more specifically on CPRC operations. New board members shall be oriented to the structure and operation of the CPRC and shall be provided continuing education at least bi-annually each fiscal year. Documentation of CPRC training will be cited in the board meeting minutes. General staff interaction with the board will occur through the Executive Director, who serves as a liaison. With prior approval of the Executive Director, staff members of the CPRC may be placed on the agenda for a subsequent board meeting in order to facilitate direct communication regarding a specific concern. This may be arranged through the Executive Assistant. Last Revised: 4/17 12

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: ORGANIZATION SECTION NO. I SUBJECT NO. 3 The Community Psychiatric Rehabilitation Center of North Central Missouri Mental Health Center shall provide the full range of CPRC services to each community and the encompassing service area. The CPRC Director shall administer the operation components that collectively deliver the following core services: 1. Intake/Annual Psychosocial Evaluation (PSI/PSA); 2. Community Support; 3. Psychosocial Rehabilitation Center (PSRC); 4. Crisis Intervention and Resolution; 5. Medication Services; and 6. Medication Administration. Last Revised: 4/17 13

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: LOCATION AND HOURS SECTION NO. I SUBJECT NO. 4 The Department of Mental Health shall designate the minimum geographical boundaries of service areas throughout the state. Exceptions shall only be granted by the Director upon appeal from prospective providers. CPRC Services are offered days, evenings and weekends as client need deems appropriate. CPRC Services cover the following nine counties: Caldwell, Daviess, Grundy, Harrison, Linn, Livingston, Mercer, Putnam and Sullivan. Main service sites are located in Trenton and Chillicothe. Crisis services are offered 24-hours a day, seven (7) days a week. Last Revised: 4/17 14

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: PHILOSOPHY AND PURPOSE SECTION NO. I SUBJECT NO. 5 All program components of North Central s CPRC share a common philosophy that is expressed through the following principles and values: 1. Persons with a serious mental illness shall be active participants in program planning as well as individualized service planning, consistent with individual abilities. Clients are entitled to be treated with dignity and respect and have crucial roles to play in helping themselves and others to lead productive and satisfying lives. 2. Individuals who have a serious mental illness are capable of making decisions about where and how they want to live, learn, work and socialize, and will be given every opportunity and support needed to make such decisions regarding their lives. 3. Individuals disabled by a serious mental illness can lead far more rewarding and productive lives in the community, often including extensive and successful periods of employment made available to them. 4. Community-based services, including social, education, and vocational rehabilitation opportunities, are effective in assisting individuals to realize their potential for community living. 5. Services of the CPRC must be available and accessible. Organized outreach and transportation are necessary to reach those in the service area who are considered most in need of assistance for rehabilitative services. The CPRC program shall provide CPRC services to the eligible residents of a designated service area to the extent that adequate program/facility/funding capacity is available. 6. CPRC services must be responsive to the needs of clients, rather than the needs of the service system or those employed by it. 7. The scope and array of services and opportunities provided by the CPRC must be broad enough to accommodate the preferences and the diverse Last Revised: 4/17 15

needs of each client. All basic program components will be available to varying levels of intensity, based on individual need and readiness. 8. Continuity and coordination of care across program components are essential in providing quality mental health services. 9. A multi-disciplinary team approach to service delivery is the model that best assures quality and continuity of care and services to the client. 10. Services are offered (based on capacity) to all who need them without regard to gender, race, color, religion, nation origin, impairment status, veteran status, marital status, social or economic conditions, length of local residency, age or any characteristics associated with emotional disability or illness. Last Revised: 4/17 16

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: OUTREACH PLAN FOR SERVICES SECTION NO. I SUBJECT NO. 6 All services of the CPRC will be made available to as many eligible clients as program size/funding permits and/or as the program expands. A policy of outreach to unserved and under-served individuals will be implemented through educational presentations, brochures, media, maintaining liaison with referring agencies, and participation by key agency personnel in community service organizations. The CPRC Director and program staff will be responsible for providing information on the full range of CPRC services to the general public, potential referral sources, and to the client population. The CPRC program provides the following services and liaison activities to the criminal and/or juvenile justice systems. This is done by: 1. Promotion of effective relationships with local law enforcement systems, including courts, through training education and consultation; 2. Information for law enforcement, court, juvenile offices and probation/parole personnel about services offered by the CPRC provider; 3. Provision of CPRC services to persons with serious mental illness who are on parole, probation, or in forensic aftercare, as appropriate, and working closely with the parole/probation officer, juvenile officer, and department forensic aftercare workers within the limits of confidentiality. The CPRC program shall provide the following services and liaison activities to state and local public assistance/housing agencies and employment/training agencies: 1. Promotion of effective relationships with state and local public assistance/housing agencies and employment/training agencies through training, education, and consultation; 2. Information for personnel of state and local public assistance/housing agencies that provide public benefits about services offered by the CPRC program; Last Revised: 4/17 17

3. Provision of assistance to persons with serious mental illness and seeking public benefits, and in working closely with staff of state and local public assistance/housing and employment/training agencies within the limits of confidentiality to expedite the application process and continuation of client s eligibility. Last Revised: 4/17 18

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: CLIENT FEEDBACK AND RECOMMENDATIONS SECTION NO. I SUBJECT NO. 7 The NCMMHC Board of Directors shall solicit recommendations and feedback from clients, client family members and client advocates regarding the appropriateness and effectiveness of services, continuity of care and treatment through the Consumer Satisfaction Survey. In establishing a formal mechanism to solicit recommendations and feedback from primary clients, the Board of Directors, Executive Director, Clinical Director, Quality Assurance Coordinator, and CPRC Director will utilize the following process at least annually: 1. Evaluate an instrument to gather data; 2. Distribute the instrument to CPRC primary clients, family members, and/or guardians; 3. Retrieve data from the instrument to assess needs and feedback; 4. Develop an implementation plan to resolve cited issues; and 5. Incorporate recommendations and action steps into the Quality Assurance plan. Last Revised: 4/17 19

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: PROGRAM GOALS SECTION NO. I SUBJECT NO. 8 As a reflection of the North Central Missouri Mental Health Center philosophy, the CPRC staff strives, through programs and services, to provide individualized normalization, community integration, independent functioning and rehabilitation in order to: 1. Reduce the frequency and length of psychiatric hospitalization; 2. Help the client learn the basic skills and attitudes necessary for competitive employment or successful learning environment; 3. Provide a setting in which clients can learn to develop stable and supportive relationships; and 4. Provide a setting in which clients can acquire the skills necessary to cope with the stress of living as independently as possible in the community. Last Revised: 4/17 20

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: RESEARCH SECTION NO. I SUBJECT NO. 9 North Central Missouri Mental Health Center is supportive of research activities as long as its primary goal of service to individuals is not compromised. Persons wishing to conduct research at NCMMHC must first obtain the approval of the agency s Review Task Force, to be approved by the Management Team. A complete procedural proposal detailing recruitment, instruments, and protection of subjects shall be submitted to the Executive Director. The Executive Director will form a committee consisting of the particular program director and one or two professional staff to review the proposed research activity and to decide whether it may be conducted at NCMMHC. Final approval must be obtained from the Executive Director. No client will participate as a research subject without their voluntary, informed and timely consent. Children will only participate as research subjects with their parent(s) s written consent and their own assent. Research on Department of Mental Health clients will additionally be approved by the Missouri Department of Mental Health Professional Review Committee. NCMMHC will receive a final report on any research conducted. These reports will be kept in the administrative office. Last Revised: 4/17 21

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: CLIENT RIGHTS SECTION NO. I SUBJECT NO. 10 North Central s CPRC assures each client the following rights and privileges without limitation: 1. To receive prompt evaluation, care and treatment; 2. To receive these services in a clean and safe setting; 3. To humane care and treatment; to have the treatment/rehabilitation explained; 4. To be treated with respect and dignity as a human being and addressed in an age-appropriate manner; 5. To be the subject of an experiment or research only with client s informed, written consent or the consent of a person legally authorized to act on client s behalf; 6. To have records kept confidential in accordance with federal and state laws and regulations; 7. To have the same legal rights and responsibilities as any other citizen, unless otherwise stated by law; 8. To not be denied admission or services because of race, gender, creed, marital status, sexual orientation, national origin, disability, age, prior treatment, withdrawal from treatment against advice, or continuation or return of symptoms after prior treatment; 9. To be free from verbal, sexual and physical abuse, neglect, humiliation, corporal punishment, threats or exploitation; 10. To refuse hazardous treatment, unless ordered by the court; 11. To medical care and treatment in accordance with accepted standards of medical treatment; 12. To consult with a private, licensed practitioner at the client s own expense; 13. To request and receive a second opinion before hazardous treatment, except in an emergency; and Last Revised: 4/17 22

14. To receive these services in the least restrictive environment. Outpatient client rights and privileges which may be limited include: 1. To see own records; and 2. Limitations necessary to ensure personal safety or the safety of others. CPRC staff shall explain the aforementioned to each client and/or guardian and, when applicable, to the guardian, in terms easily understood. Staff will document the explanation of program rules by use of a form signed by the client and/or guardian and the staff member, and placed in the client s clinical record. The CPRC will post program rules at service sites. The CPRC shall post the address and telephone number of the Department of Mental Health s Client Rights Monitor at service sites. The program will inform all clients that the Department of Mental Health s Client Rights Monitor may be contacted regarding any client complaints pertaining to abuse, neglect, or violation of rights or confidentiality. Last Revised: 4/17 23

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: CONFIDENTIALITY OF RECORDS SECTION NO. I SUBJECT NO. 11 The CPRC adheres to all NCMMHC policies concerning confidentiality, as well as all applicable federal and state laws and regulations with respect to the confidentiality of client records. Access to a client s confidential file will be limited to those staff working with that individual and who need this information. These records may be released to others only with the informed, written consent of the client or guardian. Depending upon the source and nature of a request for records, a verbal or written summary may be provided in lieu of a complete reproduction. Staff will handle such requests in a supportive manner consistent with a client s sense of trust in making disclosures. A client or guardian may be asked to sign a form giving consent for the CPRC to obtain his/her records from another service provider. Upon receipt, these records become part of the client s confidential file. Under no circumstances will such records be disclosed. A client or guardian may review his/her clinical record by submitting a written request to the CPRC Director. Upon receipt of the request, the CPRC Director and assigned community support specialist will review the clinical record and remove any information which could be detrimental to the client as well as any information received from another agency. All requests will be transacted within a forty-eight (48) hour time period. Photographs of clients may not be taken without the client s or guardian s written consent and knowledge of the intended use of the photographs. Exceptions to this restriction will be granted for specific purposes of client identification, maintaining the client record, or recording special events involving clients. Last Revised: 4/17 24

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: CLIENT ABUSE AND NEGLECT SECTION NO. I SUBJECT NO. 12 Policies regarding the abuse or neglect of clients are pursuant to 9 CSR 10-5.200. I. DEFINITION OF ABUSE AND NEGLECT Neglect: Neglect shall be defined as the absence of behaviors on the part of the primary clinician such as not returning phone contacts, missing or consistently arriving late for appointment, or other behaviors of not maintaining the intended program components. Neglect of clients will not be tolerated and will be addressed through disciplining measures. Neglect includes, but is not limited to, failure to provide adequate supervision during an event in which one client causes serious injury to another client; failure of an employee to provide reasonable and necessary services to maintain the physical and mental health of any client when such failure presents either imminent danger to the health, safety or welfare of the client, or a substantial probability that death or physical injury would result; or failure of an employee to provide reasonable or necessary services to a client according to the individualized treatment plan, or according to acceptable standards of care. This includes action or behavior that may cause psychological harm to a client due to intimidating, causing fear, or otherwise creating undue anxiety. Physical Abuse: Purposely beating, striking, wounding or injuring any client or in any manner whatsoever mistreating or maltreating a client in a brutal or inhumane manner. Physical abuse includes handling a client with any more force than is reasonable or apparently necessary for preventing the client from harming self or others. Sexual Abuse: Any touching, directly or through clothing, of a client by an employee for sexual purpose or in a sexual manner. This includes, but is not limited to: 1. Kissing; 2. Touching of the genitals, buttocks, or breasts; 3. Causing a client to touch the employee for sexual purposes; Last Revised: 4/17 25

4. Promoting or observing for sexual purpose any activity or performance involving clients including any play, motion picture, photography, dance, or other visual or written representation; or 5. Failing to intervene or attempt to stop or prevent inappropriate sexual activity or performance between clients. Verbal Abuse: Verbal Abuse includes, but is not limited to, an employee making a threat of physical violence to a client, when such threats are made directly to a client or about a client in the presence of a client, or an employee using profanity or speaking in a demeaning non-therapeutic, undignified, threatening or derogatory manner to a client or about a client in the presence of a client. II. PERSONNEL 1. The agency shall employ no person known by the administration to have committed physical abuse, sexual abuse, neglect, or a felony involving crimes against persons. 2. The agency shall employ no person known by the administration to have committed verbal abuse or neglect three (3) or more times within a twelve (12) month period. III. REPORTING ALLEGATIONS OF ABUSE AND NEGLECT 1. Complaints shall be filed with the Executive Director. a. Any person may make a verbal or written complaint to the Executive Director or any other agency employee. b. Any employee, including employees receiving complaints, having reasonable cause to believe that a client of NCMMHC has been subjected to physical abuse, sexual abuse, neglect, or verbal abuse while under the care and supervision of NCMMHC shall immediately complete and file a complaint with the Executive Director. Failure to report is cause for disciplinary action, or criminal prosecution, or both. c. NCMMHC staff shall respond to incidents/accidents involving clients, other staff members and/or visitors to assist with emergency procedures as needed. Permission must be obtained from involved persons prior to providing assistance whenever possible. All incidents, accidents, or procedural errors which cause Last Revised: 4/17 26

harm or potential harm to clients, staff members, and/or visitors must be reported verbally to the supervisor within the same working day as the occurrence, and within 24 hours in writing to the Executive Director or designee. 1. Examples include, but are not limited to: a) Falls, burns, electric shock b) Error in client care procedures, including medication errors c) Errors in diagnostic or therapeutic procedures d) Failures to obtain informed consent from client e) Personal property loss or damage f) Accidents or injuries involving clients, staff members, or visitors g) Attempted or actual suicide h) Attempted or actual assault i) Abuse and/or neglect of a client j) Harassment or threats k) Death l) Homicide m) Physical restraint n) Client rights violation o) Elopement 2. Each staff member involved in, or witnessing an incident addressed by the policy will complete a written incident report within 24 hours of when the incident occurred or was discovered. a) Each incident report will be completed and given to an available secretary to type that same day. Once the report is typed, it must be signed by the appropriate staff member. b) The report will be given to the Executive Director for review and signature. c) The Executive Director will review the report with Last Revised: 4/17 27

the Clinical Director. Any actions taken will be described in writing and forwarded to the Department of Mental Health. Reports will then be kept separately in a locked file in the Executive Assistant s office. d) The Clinical Review Committee will review all incident/accident reports on a quarterly basis. d. Staff shall provide basic life support (CPR and/or First Aid) and take any secondary steps such as calling an ambulance, and staff will identify and report all undesirable incidents, accidents, service delivery problems or situations which contain the potential for harm to clients, visitors, or staff which might be the result of breach of duty by the responsible staff, the responsible unit, and/or the agency. e. Any staff witnessing or the first to arrive upon the scene of an accident, cardiac arrest, or injury must take steps to provide or assure provision of CPR and/or First Aid. If the staff member is not trained in CPR or First Aid, then s/he is to secure help from those so trained; first from staff or others present, or by calling location hospital emergency personnel for assistance. f. Immediately after the emergency, the staff person involved in an accident, witness to an accident, or first to arrive at the scene will first verbally report to his/her supervisor, and then complete the Incident and Investigation Tracking System-Event Report Form and route this form to the Executive Director or designee. g. Reporting procedures for all deaths, serious injuries, elopements and other serious incidents shall follow the Department of Mental Health guidelines as included in the Attachment (Attachment A) section of these policies and procedures. 2. If an incident of physical abuse, neglect or sexual abuse occurs to a minor, the agency employee receiving the complaint or having knowledge of the incident shall report the incident to the Division of Family Services on the toll-free hotline number (1-800-392-3738) Last Revised: 4/17 28

immediately, in addition to reporting as set out in Section 1. 3. If an incident of physical abuse, neglect or sexual abuse occurs to an adult, the agency employee receiving the complaint or having knowledge of the incident shall report the incident to the Division of Aging on the toll-free hotline number (1-800-392-0210) immediately, in addition to reporting as set out in Section 1. 4. Upon receiving a complaint, the Executive Director shall: a. Immediately report the complaint to the appropriate licensing agency, to all agency staff who are professionally involved with the client, and send a copy of the complaint to the Client s Rights Monitor. b. Determine whether an incident report should be submitted to the Regional Director of the Department of Mental Health Central Office, and if so, facilitate the submission of that report according to DMH guidelines. c. Within five (5) days after receiving the complaint, send a letter acknowledging the receipt of the complaint to the person who filed the complaint. IV. INTERNAL INVESTIGATION PROCESS 1. In the case of injury and/or death of a client in his/her residence or community, the CPRC staff will review the occurrence to determine the need for further investigation if there is reason to believe that abuse or neglect occurred. 2. Investigations of all complaints of sexual abuse, physical abuse or neglect shall be initiated by the Executive Director immediately. 3. The Executive Director, CPRC Director and Clinical Director shall review each incident of abuse or emergency restraint within five (5) working days of its occurrence. 4. Investigations of neglect or verbal abuse shall be initiated within twentyfour (24) hours. a. Investigations shall include, but not be limited to, signed written statements from all persons with information regarding the complaint, including witnesses, victims or alleged perpetrators and Last Revised: 4/17 29

appropriate supporting documents. b. The investigation of each complaint shall be completed within 30 days. 5. The Executive Director may have a medical examination completed as soon as possible by a licensed physician, or registered nurse if a physician is not available, on any client named in any complaint of physical abuse, sexual abuse, or neglect, and a copy of the examination regarding the injury and treatment shall be placed in the client s chart. V. LOCAL DEPARTMENT OF MENTAL HEALTH INVESTIGATION PROCESS 1. The head of the facility, day program, or specialized service that is licensed, certified or funded by the Department shall immediately report to a local law enforcement official any alleged or suspected: a. Sexual abuse; b. Abuse or neglect that results in physical injury; or c. Abuse, neglect or misuse of funds/property which may result in a criminal charge. 2. If a complaint has been made under this rule, the head of the facility or program, and employees of the facility, program or service, shall fully cooperate with law enforcement and with Department employees or employees from other agencies authorized to investigate the complaint. Failure to cooperate may result in contract termination or dismissal of the employee. 3. A board of inquiry, local investigator assigned by the Department, or the Department s central investigative unit shall gather facts and conduct an investigation regarding the alleged abuse or neglect. The investigation shall be conducted in accordance with the procedures and time frames established under the Department s operation regulations. Upon completion of its investigation, the board if inquiry, local investigator, or central investigative unit shall present its written findings of facts to the head of the supervising facility. 4. Within ten (10) calendar days of receiving the final report from the board of inquiry, local investigator or central investigative unit, the head of the supervising facility or Department designee shall send to the provider and Last Revised: 4/17 30

alleged perpetrator a summary of the allegations and findings which are the basis for the alleged abuse/neglect. The summary shall be sent by regular or certified mail. a. The provider and/or alleged perpetrator may meet with the head of the supervising facility or Department designee and submit comments or present evidence. If the provider or alleged perpetrator wishes to have this meeting, s/he must notify the head of the supervising facility or department designee within ten (10) calendar days of receiving the summary. b. This meeting shall take place within ten (10) calendar days of notification, unless the parties mutually agree upon an extension. c. Within ten (10) calendar days of the meeting, the head of the supervising facility or Department designee shall sustain or deny the allegations as to whether abuse/neglect took place. The provider and the alleged perpetrator shall be notified of this decision by certified mail. d. The letter shall advise the provider and alleged perpetrator that they have ten (10) calendar days to contact the Department s hearing officer if they wish to appeal a finding of abuse or neglect. e. If there is no appeal, the decision of the head of the supervising facility or Department designee shall be the final decision of the Department. 5. If an appeal is requested, the hearing officer shall schedule the hearing to take place within 30 calendar days of the request, but may delay the hearing for good cause shown. At the hearing, the head of the supervising facility or designee, or other Department designee, shall present evidence supporting its findings of abuse, neglect, or both. The provider or alleged perpetrator may submit comments or present evidence to show why the decision of the head of the supervising facility or Department designee should be modified or overruled. The hearing officer may obtain additional information from Department employees as Last Revised: 4/17 31

s/he deems necessary. 6. The decision of the hearing officer shall be the final decision of the Department. The hearing officer shall notify the provider, alleged perpetrator, and the head of the supervising facility or Department designee by certified mail of the decision within 14 days of the appeal hearing. 7. The opportunities described in Sections 4, 5 and 6 of this rule regarding a meeting with the head of the supervising facility and an appeal before the Department s hearing officer apply also to providers and alleged perpetrators in an investigation of misuse of client funds/property. 8. A provider or alleged perpetrator does not forfeit his/her right to an appeal with the Department s hearing officer when s/he declines to meet with the head of the supervising facility under Subsection (4) (a) and (b) of this rule. 9. If the Department substantiates that a person has perpetrated physical abuse, sexual abuse, neglect, or conversion of client s property and/or funds for his/her own use or the facility s use, the perpetrator shall not be licensed, employed, nor provide services by contract or agreement at a residential facility, day program, or specialized service that is licensed, certified, or funded by the Department. 10. If the Department substantiates that a person has perpetrated verbal abuse or neglect two (2) or more times in a 12-month period, the perpetrator shall not be licensed, employed, or provide services by contract or agreement at a residential facility, day program or specialized service that is licensed, certified, or funded by the Department. 11. In accordance with 9 CSR 10-5.190, no person convicted of specified crimes may serve in facilities or programs licensed, certified, or funded by the Department. AUTHORITY: Sections 630.050, 630.165, 630.167, 630.168, and 630.170 RSMo Supp. 1997 and 630.135, 630.655, and 630.705 RSMo 1994. *Original rule filed October 29, 1998, effective May 30, 1999. Last Revised: 4/17 32

VI. DISCIPLINARY ACTION 1. Any abuse or neglect resulting or suspected of resulting in physical injury (or sexual abuse of any kind) shall be reported immediately to the appropriate law enforcement agency. Any abuse or neglect, including sexual abuse, resulting or suspected of resulting in physical injury shall be reported immediately to the appropriate law enforcement agency. Within confidentiality guidelines, the Executive Director should request documentation of the findings of any criminal investigation of the incident, for inclusion in the client s chart. Last Revised: 4/17 33

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: INAPPROPRIATE CLIENT BEHAVIOR SECTION NO. I SUBJECT NO. 13 This policy is intended to provide firm, fair and effective rules and consequences for inappropriate behavior of clients when engaging in Community Psychiatric Rehabilitation Center programming. In order to maintain a safe, supportive environment, loitering, physical aggression, verbal abuse, and harassing or threatening behavior or statements will not be tolerated from clients who are engaging in CPRC activities. When tact and sensitivity prove inadequate to restore order and self-control, an employee has the authority to require a disruptive or dangerous individual to leave the premises or activity. When instruction is given, the employee staff member should ensure that it is obeyed. If necessary to protect clients or staff, local law enforcement should be summoned. Alcohol or street drugs are not allowed on NCMMHC premises, in agency vans or at any activity of the CPRC program. If an individual arrives or becomes intoxicated or high, temporary exclusion of the individual from proximity to other clients, at a minimum, will be expected. In these situations, asking the individuals to leave may not always be appropriate. As circumstances warrant, protective measures will be taken by the employees in charge, including summoning local law enforcement if necessary. If the behavior or incident causes a crisis requiring professional intervention, procedures for implementation of the client s critical intervention plan will be followed. (See Behavioral Crisis, Section I, Subject 15.) Last Revised: 4/17 34

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: BEHAVIOR MANAGEMENT SECTION NO. I SUBJECT NO. 14 The Community Psychiatric Rehabilitation Program has an obligation to protect the physical and mental welfare and safety of clients and staff in an environment that nurtures personal growth and dignity. The CPRC staff will use positive redirecting approaches to behavioral interventions that have an emphasis on building positive relationships and promote de-escalation while empowering clients to manage their own behaviors successfully. Problematic or disruptive behaviors, including but not limited to broken rules, loitering, or harassment/threats, will be managed and de-escalated through verbal measures of staff and/or involvement of a QMHP or the client s community support specialist. CPRC staff will be firm, consistent and positive in all control and disciplinary situations. Staff will use early positive intervention and reinforcement as a first step in control and discipline. When necessary, a QMHP will be summoned to intervene with verbal measures aimed at de-escalating the situation at the service site. If a client s behavior becomes uncontrollable, every attempt will be made to calm and control the client. If the behavior becomes a threat to the safety of the client or others, physical intervention may be necessary. If the situation cannot be controlled and the client is out of control or endangering the safety of him/herself or others, law enforcement will be called at 911 and an incident report shall document the client s behavior. Aversive conditioning of any kind (e.g. withholding of food, water or bathroom privileges; painful stimuli; corporal punishment; or use of seclusion, restraint, time out, discipline or coercion for staff convenience) is prohibited. Repeated or ongoing behavioral problems will be reported to the community support specialist and addressed in the treatment plan or appropriate short and longrange interventions. Progress notes, or when appropriate an incident report, shall document the client s behavior. Last Revised: 4/17 35

The CPRC s behavior management policies are to be responsive to feedback received from its clients and their family members, guardians, or advocates. For appropriate emergency responses to explosive behavior, refer to policies concerning inappropriate client behavior (which precedes this section) and to behavioral crises (which follows). Last Revised: 4/17 36

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: BEHAVIORAL CRISES SECTION NO. I SUBJECT NO. 15 A behavioral crisis will be regarded as a situation involving the isolated behavior of a specific client or an interaction between clients that is either explosive, imminently assaultive, or otherwise requires emergency response to protect the safety of those present. When clients show signs of fear, anger, or pain which may lead to aggression or agitation, staff members are trained to recognize and respond to these signs through de-escalation, changes to the physical environment, implementation of meaningful and engaging activities, redirection, active listening, mediation, conflict resolution, etc. Seclusion and restraint are not used and are never considered treatment interventions. Briefly holding a client without undue force, for the purpose of comforting him/her or to prevent self-injurious behavior or injury to self, or holding a client s hand or arm to safely guide him/her from one area to another is not a restraint. Separating individuals threatening to harm one another, without implementing restraints, is not considered a restraint. Voluntary time out is not considered seclusion, even though the voluntary time out may occur in response to verbal direction. The CPRC program shall take steps which are reasonable and necessary to maintain the physical and mental health of clients and staff when failure to take such steps presents either an imminent danger to the health, safety or welfare of the clients or staff, or a substantial probability that death or serious physical harm will result. No employee or volunteer shall use any more force than is reasonably necessary for the proper control, treatment or management of such client. Available staff will usher all uninvolved clients safely away from the immediate area. The appropriate community support specialist and the CPRC Director will be contacted immediately. Depending upon the underlying reason for the incident and appropriate clinical judgment of the CPRC Director, temporary or permanent denial of CPRC services to the offending client may result, or steps may be taken to arrange for psychiatric intervention as deemed appropriate. Last Revised: 4/17 37

Last Revised: 4/17 38

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: MEDICAL EMERGENCIES SECTION NO. I SUBJECT NO. 16 If a client experiences a medical crisis or emergency while on NCMMHC premises or engaged in CPRC activities, the following procedures are to be followed: 1. The first staff person to become aware of the emergency must initially determine whether to intervene immediately with CPR or other first aid measures, if trained, before calling 911 or other emergency response services and alerting other staff. 2. After this initial judgment has been made, the CPRC Director or designee shall perform the following duties, in order, as the situation dictates: a. Call local law enforcement (if appropriate to the situation or if this has not already been done). b. Summon or consult a physician or nurse, if one is on site, for appropriate intervention, or seek emergency response services if medical help is not readily available. c. Ensure that a qualified staff person begins CPR or other first aid procedures as appropriate until emergency personnel arrives. d. Consult the client s chart to ensure familiarity with any relevant medical information (e.g. allergies, drug interactions). e. Notify the client s guardian, spouse or other involved person as appropriate. f. Depending on the severity of the emergency and its resolution, ensure that involved staff completes an EMT-Community Event Report Form ADA/CPS (Attachment A) within twenty-four (24) hours. Last Revised: 4/17 39

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: OFF-SITE EMERGENCIES SECTION NO. I SUBJECT NO. 17 Emergencies in client homes and other off-site locations are to be handled by the staff present in a manner as similar to on-site emergencies as is feasible. If time permits, the staff member present should contact the CPRC Director regarding available options. When appropriate, emergency services (e.g. 911, local law enforcement, fire department, ambulance) will be called. The safety of clients and staff is of the utmost consideration in making judgments in the handling of any emergency situation. Last Revised: 4/17 40

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: EMERGENCY RESPONSE IN CASE OF VEHICLE ACCIDENT SECTION NO. I SUBJECT NO. 18 1. When a vehicle accident occurs, to ensure safety of all passengers, employees should evacuate the vehicle if necessary. Employees should not remove injured passengers unless absolutely necessary for safety (risk of fire, explosion, etc.). Basic First Aid or CPR should be administered and an ambulance should be summoned if needed. As soon as possible, local law enforcement should be notified. 2. The vehicle should not be moved before local law enforcement has arrived at the scene. Proof of insurance should be located in the glove compartment. Employees shall be cooperative with law enforcement in providing all necessary information. 3. Employees shall contact the CPRC Director or designee as soon as possible for assistance in managing the agency response to the accident. 4. If the vehicle is disabled, employees on the scene shall contact the agency to arrange for pickup of stranded employees and clients and to have tow or emergency road service arranged. 5. Upon return from the accident scene, employees shall notify the CPRC Director or designee (if not already done) and the guardian (if applicable) and complete an Internal Incident Report (Attachment B) within twentyfour (24) hours. The NCMMHC employee will complete a DMH EMT incident report if a client was involved. Last Revised: 4/17 41

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: INFECTION CONTROL: AIDS SECTION NO. I SUBJECT NO. 19 The CPRC infection control policy is designed to control and reduce the rate of infection and transmission of infectious disease. The Federal Government issued proposed regulations in 1987 that would require employers in health-related fields to provide greater protection for employees, and require employers to provide educational programs, protective supplies, and a safe environment for disposing of medical waste. NCMMHC supports those proposed regulations by taking proper precautionary measures against contamination and spread of infection, providing necessary protective supplies, and providing educational materials and inservice education. NCMMHC recognizes this as an agency responsibility as well as each individual employee s personal responsibility. Due to the concern regarding AIDS and its implications to employees of NCMMHC, a specific policy for preventing transmission of AIDS has been developed. In compliance with the Federal Center for Disease Control, these guidelines are therefore incorporated into the CPRC s infection control policy. Since AIDS is not spread through the normal, casual contact that occurs in the workplace, NCMMHC recognizes that workers who are HIV positive or have AIDS have a lot to offer both professionally and personally. Co-workers in turn can be an important source of support. Last Revised: 4/17 42

NORTH CENTRAL MISSOURI CPRC MENTAL HEALTH CENTER MANUAL SECTION: ADMINISTRATION SUBJECT: INFECTION CONTROL: ALL DISEASES SECTION NO. I SUBJECT NO. 20 Infection control procedures address infections spread through bodily fluids; these include, but are not limited to, hepatitis A, B and C; HIV, STD s, etc. Infection control should include the following general guidelines: 1. Hand washing. 2. Universal handling of blood and body fluids. 3. Mouthpieces for CPR. 4. Education. 5. Community-based programs guidelines. 6. Use of disinfectant: 1 part bleach to 10 parts water is recognized as effective in killing the HIV+ virus and other infectious elements NCMMHC has recognized the need for education and has provided for the opportunity to network with community, state and federal resources to obtain cooperation in case of an outbreak of infectious or contagious disease. When it is suspected that a client has contracted an infectious or contagious disease, s/he will be encouraged or assisted to seek immediate medical attention. If necessary, the client may be asked to sign a release form so that the physician can be contacted for further information concerning the diagnosis. If the CPRC Director has reason to believe that there is a risk of infection to other clients, the county health department will be contacted for guidance concerning precautionary measures to be taken. Temporary suspension of a client from attendance or involvement in CPRC activities for the contagious period of an infection may be one such measure. The CPRC Director may require a physician s statement as a condition for resuming attendance to CPRC activities. In any instance of serious infectious or contagious disease affecting a Department of Mental Health placement in a group or residential setting, the Residential Services Liaison will be notified and involved in planning for intervention. If risk of contagion is a concern after consultation with the public health nurse, the Department of Last Revised: 4/17 43